New rules from 1 December: sick leave without extra tests limited to five days

From 1 December a new rule will shorten the period during which a family doctor may certify sick leave without additional diagnostic criteria from seven days to five. After the fifth day, continuation of absence from work will require diagnostic tests and/or specialist assessments depending on the diagnosis, a change that has prompted concern among patients and primary care physicians about timely access to the required documentation.

Key changes and practical concerns

The Health Insurance Fund (HIF) says the new regulation does not force patients to return to work after the fifth day: family doctors will still be able to approve sick leave up to 15 days, and longer absences will be decided by the Fund’s medical commission. For certain diagnoses patients will need earlier referral for further testing and evaluation.

"The changes do not curtail the right to sick leave, nor do they limit its duration when there is a medically justified need," the HIF states in a written response. The Fund also notes that, in medically justified cases, a family doctor can issue a priority referral so patients gain faster access to a specialist.

However, the HIF acknowledges the regulation does not precisely define what will happen when a patient cannot obtain the necessary specialist appointment in time and there is no medical basis for a priority referral. "The mere existence of a waiting list does not automatically justify ending sick leave or the right to compensation," the Fund emphasizes.

Doctors’ organisations say some of their comments were accepted during preparation of the new criteria, but reservations remain. Dragan Gjorgjievski, president of the Association of Doctors ZLOM, says that for some diagnoses it is reasonable to refer patients earlier to a medical commission, while criteria for other conditions need further review. He says not all the association’s proposals were accepted and expects further talks on unresolved issues.

Dr Lilija Chulakova Dervishova, president of the Association of Private Doctors, says the Fund found certain abuses during inspections of family practitioners. She does not expect major problems with referrals for additional tests or for commission review, but stresses that recovery times vary by condition: "In medicine, two plus two is not always four."

Some physicians say they still lack sufficient information on the practical application of the regulation. Miroslava Shevchenko, vice-president of ZLOM-SM, writes that "many things are still not clear to us as primary care doctors." An open debate with the Fund is scheduled for 20 November, where doctors expect more detailed explanations; the Fund has also planned workshops with selected physicians on 19 and 20 November.

The regulation, published in the Official Gazette on 30 October, also tightens conditions for long-term sick leave. As a rule, extensions beyond 60 days will require a consiliary opinion from three specialists or subspecialists, valid for up to 60 days. Exceptions are provided for patients with malignant diseases, severe stroke with heavy consequences, multiple sclerosis, polytrauma and terminal conditions, for whom such opinions are not mandatory. The specified duration for a diagnosis may be exceeded when medically justified, subject to renewed documentation and assessment by the medical commission.

For chronic patients, prior diagnostic results may be used if the specialist considers them adequate: diagnostic documents should not be older than six months, while radiodiagnostic findings may be up to one year old. If within 30 days after closing a sick leave the need for absence reappears due to a diagnosis from the same group, the family doctor must submit a proposal to the medical commission—except when hospital treatment for the same diagnosis is required, which does not need prior commission approval. The rule foresees the possibility of retroactive opening of sick leave—generally one day back—when the patient contacts the family doctor on the next working day following the onset of incapacity. Reports will be generated electronically, and seriously ill, immobile or hospitalized patients need not appear in person when allowed under the regulation. Insured persons who disagree with a medical assessment may file an objection with the competent medical commission.

The HIF expects the new model to simplify procedures and clarify medical criteria, but questions remain about how uninterrupted continuation of sick leave will be ensured for patients who cannot obtain timely specialist appointments. The Fund says the new rules will also apply to sick-leave procedures that began before 1 December and are still ongoing.

Photo: press material from the event